Every day I have a conversation relating to electronic claiming in pharmacies and automation of payments at Practitioner and Counter Fraud Services (P&CFS). I’d like to briefly describe the differences and the impact this can and will have on payments.

Electronic claims can be submitted for barcoded prescriptions which make up around 88% of all prescriptions submitted. When the physical prescription is received at P&CFS, a process is in place to attempt automation of the electronic claim. If the claim fits a number of criteria (legal prescription, prescribed and dispensed item match, quantity is within tolerance etc.) it will pass directly for payment. The claim will have no human intervention and will be paid and listed on the items paid report for the pharmacy.

For a number of reasons including automation down time, items not eligible for automation, quantity dispensed outside of tolerance level, some claims will not proceed for payment and will require some kind of human intervention. P&CFS are introducing systems to pay from a visual manifestation of the electronic information commonly called the virtual form. Where the claim does not automate, P&CFS can still refer to the virtual form and use it to pay if there is sufficient information. If the virtual form information is unavailable or invalid, as a last resort the scanned image will be used to process the prescription.

Download this blog post as a PDF to see an example of where this can cause problems with payment of methadone prescriptions. We have seen a number of prescriptions where an electronic claim has been submitted for the quantity dispensed only, with no endorsements for instalments or supervisions. Many contractors know that methadone is not automated, however, it can still be paid from the electronic claim information submitted and the above example represents a risk to your income. Does your pharmacy receive methadone prescriptions with barcodes? If so I would recommend looking into this.

Another example included in the PDF is where the pharmacy has hand endorsed out of pocket expenses and special price information for unlicensed medicines on paper. If this is not replicated in the electronic claim, PSD will pay the on list price they hold for the item which can sometimes vary from what contractors are claiming. Also, no electronic claim for out of pocket expenses means these will not be paid either.

The advice we have issued is to ensure the electronic claim is identical to the paper endorsements added. If you have any questions on the relevant endorsements, please get in touch with my team in the office by e-mail at pharmacy.services@cps.scot or phone on 0131 466 3540.